Provider Demographics
NPI:1609398734
Name:PROCARE FOOT AND ANKLE, LLC
Entity Type:Organization
Organization Name:PROCARE FOOT AND ANKLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EBONY
Authorized Official - Middle Name:B
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:678-489-4210
Mailing Address - Street 1:950 EAGLES LANDING PKWY # 592
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7343
Mailing Address - Country:US
Mailing Address - Phone:678-489-4210
Mailing Address - Fax:678-489-4088
Practice Address - Street 1:300 PRIME POINT, SUITE 100
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-6851
Practice Address - Country:US
Practice Address - Phone:678-489-4210
Practice Address - Fax:678-489-4088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-11
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric